A “snapshot” of this moment in PCa treatment
I came across a journal article by a Brazilian urologic specialist, Dr. Stênio Cássio Zequi of the Camargo Cancer Center in São Paulo, Brazil.[i] He asks if focal therapy will be the next step in prostate cancer (PCa) management. Before expressing his opinion, he writes what amounts to a “snapshot” of the current state of PCa treatment.
Dr. Zequi points out that whole gland therapy (WGT) such as radical prostatectomy, beam radiation, seed implants, cryotherapy and HIFU) continues to dominate the field of treatment options, despite the fact that early detection turns up many low-risk cases in which PCa is only in 5-10% of the gland. Admittedly, cancer control and survival rates are very good with these radical treatments. However, they are associated with high rates of urinary, sexual and bowel morbidities (side effects).
At the same time, there is a growing trend to offer Active Surveillance (AS) to newly diagnosed patients where there is a high degree of confidence that their cancer is indolent and/or clinically insignificant. Dr. Zequi writes that AS and delayed intervention “are well stablished as competitive, secure and ethical options, resulting in few urinary, sexual and intestinal side effects in short or mid-term follow-up.” However, AS comes with its own challenges: adherence to follow-up protocols, repeat lab work, MRI scans, medical visits, and anxiety can burden patients – not to mention the chance of under-staging a tumor, and the infection risks associated with repeat biopsies. Yet both radical therapy and AS, though in many respects opposite approaches, are both “absolutely ethical.” Thus, the majority of PCa patients will likely end up at one extreme or the other.
The question of focal therapy
Which brings him to the question: “Philosophically, why not adopt a ‘middle term’, in which we could treat focally the cancer that affects the small percentage of the prostate (eliminating the cancer, as with WGT) and, at the same time, maintain under surveillance the rest of the gland (similarly to AS)?”
He admits that the idea of focal therapy faces ongoing skepticism, though the number of critics is diminishing. He traces the rapid evolution from treating a minority of patients who had a small, low-risk unifocal (one location) tumor to today’s slightly broader standards. He says that the prevailing standard now is to treat the index lesion [having a lethal cell line that can become aggressive] while sparing surrounding healthy gland tissue – or even “secondary lesions that can be submitted to surveillance, as in AS protocols.”
The history of focal therapy research
Starting about 20 years ago, focal treatment began with image-guided tumor ablation using extreme cold (cryotherapy) or heat (HIFU). Different focal approaches included treating just the tumor plus safety margin, hemi-ablation (half the gland) and “hockey stick” ablation (half the gland plus a small ablation extended into the opposite gland side). Advances in imaging, specifically multiparametric MRI (mpMRI), knowledge of how PCa progresses, genomics, and more precise delivery of energy-based ablation are redefining who qualifies for focal therapy. Dr. Zequi cites numerous published studies of focally-treated patients, demonstrating comparable cancer control with WGT and very favorable side effect profiles.
Looking to the future
Looking ahead, there is a beginning acceptance about treating carefully qualified PCa patients with focal Gleason 7 – and in some cases, Gleason 8 – who have a favorable disease profile. There is also a new array of technologies capable of delivering a focal treatment: “Focal HIFU, Focal cryotherapy, laser ablation, interstitial laser thermotherapy, photodynamic therapy, irreversible electroporation, focal brachytherapy, focal radiotherapy, nanoparticles thermotherapy, interstitial thermal microwave therapy and interstitial radiofrequency ablation.”
Given all of the above, Dr. Zequi answers YES to his own question about focal therapy as the next step in prostate cancer management. Interested readers may be interested in Dr. Zequi’s entire article, which is not long but is filled with excellent information and research summaries.
At our own Sperling Prostate Center, we offer real time MRI-guided Focal Laser Ablation (FLA). We have done more of these procedures than anyone else, and our results more than satisfy Dr. Zequi’s ideal for a best-of-both-worlds treatment for PCa. In line with published studies, our patients benefit from cancer control that is competitive with whole gland therapies, yet with minimal-to-no risk of urinary or sexual side effects.
For more information, visit the Sperling Prostate Center website.
[i] Zequi SC. Focal therapy will be the next step on prostate cancer management? | Opinion: Yes. Int Braz J Urol. 2017 Nov-Dec;43(6):1013-1016.